Recurrent Haematuria In Pregnancy: A Case Report And A ...

Article ID: WMC001341 ISSN 2046-1690

Recurrent Haematuria In Pregnancy: A Case Report
And A Review Of The Literature

Author(s):Dr. Anthony Venyo

Corresponding Author:
Dr. Anthony Venyo,
Urologist, Urology Department. North Manchester General Hospital, M8 5RB - United Kingdom

Submitting Author:
Dr. Anthony K Grey Venyo,
Urologist, Urology Department. North Manchester General Hospital, North Manchester General Hospital,
Department of Urology, ManchesternM8 5RB, United Kingdom, M8 5RB - United Kingdom

Article ID: WMC001341
Article Type: Case Report
Submitted on:11-Dec-2010, 05:03:35 PM GMT Published on: 13-Dec-2010, 02:50:36 PM GMT
Article URL: http://www.webmedcentral.com/article_view/1341
Subject Categories:UROLOGY
Keywords:Haematuria, Pregnancy

How to cite the article:Venyo A . Recurrent Haematuria In Pregnancy: A Case Report And A Review Of The
Literature . WebmedCentral UROLOGY 2010;1(12):WMC001341

Source(s) of Funding:
None

Competing Interests:
None

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Recurrent Haematuria In Pregnancy: A Case Report
And A Review Of The Literature

Abstract haematuria in the absence of pregnancy can occur;
haematuria in pregnancy may be explained by the
Background “Nutcraker Phenomenon” and the haematuria usually
spontaneously settles.
An otherwise uneventful pregnancy may occasionally
be complicated by spontaneous gross or microscopic Conclusions
haematuria. The differential diagnosis of haematuria
during pregnancy includes all the causes of In a majority of cases of haematuria in pregnancy, no
haematuria in non-gravid patients. If investigation demonstrable cause can be found after investigations
confirms the absence of any of the known causes of and the bleeding spontaneously subsides in the
haematuria in the non-pregnant patient then the postpartum. The haematuria events are explained by
haematuria is labelled as “Idiopathic” and is explained rupture of small veins around the dilated renal pelvis in
by the peculiar changes in the urinary tract which has pregnancy. It is worthwhile realising that,
been induced by mechanical and hormonal factors investigations of gestational associated haematuria
related to pregnancy. Such a pregnancy induced almost invariably can be deferred until after delivery of
haematuria is almost invariably associated with the baby. Non–invasive investigative techniques like
spontaneous and complete resolution of the ultrasound scan and MRI are useful in arriving at such
haematuria after delivery of the baby and the decisions
haematuria may or may not recur in future
pregnancies. Gross spontaneous haematuria may Key words: Haematuria; Pregnancy; “Nutcraker
result in anxiety for a pregnant lady and an Phenomenon”; Idiopathic; ultrasound scan.
obstetrician who had not managed a pregnant lady
with gross haematuria before. Medical practitioners Introduction
need to be up to date with the investigation and
management of haematuria in pregnancy. Haematuria in pregnancy is classified as “Idiopathic”
only after non invasive diagnostic techniques including
Objectives blood and urine tests, ultrasound scan and at times
magnetic resonance imaging have confirmed the
To report a case of intermittent gross haematuria in an absence of organic causes of haematuria.
elderly primip and to review the literature on
haematuria in pregnancy Pregnancy associated spontaneous idiopathic
haematuria which resolves in the post natal period is
Case Report explained by changes in the renal tract in pregnancy.
Danielli and associates (1) suggested that hormonal
A 38-years-old lady presented with a history of and mechanical factors of pregnancy result in renal
recurrent gross haematuria when 24 weeks into her vein varicosities (tortuosity and dilatation) in the region
first pregnancy. Her examinations and investigations of the upper ureter and renal pelvis and this causes
including; urine microscopy and culture and sensitivity; haematuria. Danielli and associates (1) also stated
urine cytology; full blood count; serum urea and that the fact that hormones alone can cause
electrolytes; liver function tests; coagulation screen; haematuria has been proven by the observation that
ultra-sound scan of her renal tract/abdomen and pelvis oral contraceptive pills (pseudo-pregnancy) have been
did not reveal anything to account for the haematuria. known to be associated with pregnancy. Progesterone
The haematuria settled. She was listed to and oestrogen promote atonia, relaxation as well as
subsequently have flexible cystoscopy but she failed dilatation of the smooth muscles of the renal tract
to attend for the cystoscopy as well as follow-up which results in stasis and infection. It has been
appointment in the out-patients clinic six months later. suggested that stasis causes undue pressure on the
Literature review revealed: that most cases of fornix of the renal calyces resulting in the formation of
haematuria are idiopathic even though other causes of abnormal communications between the renal calyces

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and submucosal venous sinuses which is followed by q Ultrasound scan of renal tract was normal.
haematuria (2). Considering the aforementioned q Urine cytology was normal (this showed squamous
suggested aetiology of spontaneous idiopathic
haematuria in pregnancy, it would be conjectural to cells and no malignant cells).
suggest that idiopathic spontaneous haematuria would q Urine culture did not grow any organism; and the
be more common in polyhydramnios and multiple
pregnancies in comparison with single pregnancy but urine white cell count and red blood cell counts
there has not been any studies comparing the determined by flow cytometry were 10/uL (normal
incidence of haematuria in single pregnancies with range 0 – 40 u/L) and 20u/L (normal range 0 – 35
those of polyhydramnios and multiple pregnancies. u/L) respectively.
q Her full blood count results -Haemoglobin 10.6 g/dl
Case Report (normal range 11.5 – 16.5 g/dl); White blood cell
count 10.2 x 10*9/L (normal range 4-11 x 10*9/L);
A 38-years-old primigravida was referred by her platelet count 285 x 10*9/L (normal range 150-450 x
General Practitioner because of persistent/recurrent 10*9/L)
macroscopic haematuria which had been recurrent q Liver function tests were normal
over a period of two weeks. She developed painless q Coagulation screen were normal
gross haematuria at 22 weeks of gestation. The q Serum urea and electrolytes were normal.
haematuria started as frank specs of blood in her urine
and this persisted for a few days and then recurred She was reassured that her investigations were
intermittently up to the 24th week of gestation. She did normal but she would need to have a flexible
not have any dysuria or urinary frequency. She cystoscopy subsequently to complete her
admitted to being a smoker. She had no medical investigations and she was listed to have flexible
problems and was not on any medications. On cystoscopy.
examination she was found to be haemodynamically
stable and normotensive without any evidence of She did not attend for the flexible cystoscopy and she
pallor. Her General and systematic examination were failed to attend for follow- up six months later because
unremarkable. There was no evidence of any her haematuria had settled and she did not want any
tenderness on abdominal examination. Her fundal further investigation.
height was commensurate with her period of gestation.
Foetal movements were felt and it was felt that her Discussion
pregnancy was progressing smoothly. There was no
evidence of urethral caruncle on vaginal examination A number of clinical points that need to be taken into
and no evidence of bleeding from the cervix. consideration in the investigation of haematuria
include the following:
Her investigations included:
q Pelvic examination is useful in localising the source
q Urine microscopy and culture. of bleeding by differentiating renal tract bleeding
q Urine cytology. from genital tract bleeding; in doubtful cases a
q Full blood count. catheter specimen of urine may be obtained (3).
q Serum urea and electrolytes.
q Coagulation screen. q In microscopy of mid-stream specimen of urine, the
q Ultra-sound scan of renal tract and abdomen as well upper limit of normal is 1-2 red blood cells per high
power field using semi-quantitative technique and
as pelvis. 8000 red blood cells per ml using a counting
chamber (4).
It was explained to her that the haematuria would
eventually resolve in the absence of any organic q Urine microscopy may confirm presence or absence
cause and she would be treated expectantly adopting of schistosoma haematobium ova in the urine.
a conservative approach.
q Urine specimen should be sent for culture and
At follow-up four weeks later (when she was 28 weeks sensitivity and in case of evidence of urinary tract
pregnant) she reported no further significant infection adequate treatment should be given based
haematuria; her investigations were reported as upon antibiotic sensitivity.
follows:
q Urine cytology would help exclude atypical cells or
malignant cells.

q Coagulation screen is a useful test to exclude
correctable coagulation problems.

q Ultrasound scan of renal tract which is not invasive
should be used to exclude organic causes of
haematuria to arrive at a diagnosis of idiopathic
haematuria; Occasionally Magnetic Resonance
Imaging may be used.

q Cystoscopy would help in finding out organic causes
of haematuria and would also localise the source of
bleeding whether bladder or ureter and which ureter

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(5). Flexible or rigid cystoscopy may confirm the (b) Post partum follow-up be recommended to detect
presence or absence of tumour or stone in the women who have persistent haematuria and be
bladder or blood exuding from one or both ureteric presumed to have underlying glomerulonephritis (7).
orifices. Rarely, it may be necessary to do ureteric
catheterisation for urine sampling for microscopy, In 1972, De Schepper attempted to explain the
culture and sensitivity as well as for retrograde phenomenon of Idiopathic haematuria by using the
ureteropyelogram. In the case where urine is seen to “Nutcracker theory” (8). The left renal vein is subject to
be exuding from one ureter and retrograde compression between the abdominal aorta and
ureteropyelogram is normal, then ureteroscopy is a superior mesenteric artery resulting in resistance to
useful way of excluding a small lesion in the upper venous outflow in the left renal vein. This leads to the
renal tract. development of an extensive collateral venous
q If haematuria recurs in a subsequent pregnancy drainage system involving the gonadal capsular,
when all investigations have been normal then suprarenal, lumbar, azygous and periureteral veins
selective renal angiography may be indicated in the (9).. The extensive renal varicosities emanating from
post natal period to exclude an arterio-venous these collaterals gives rise to haematuria following
malformation their rupture into the renal calyces. This is diagnosed
on renal angiography and venography and this can be
Some of the causes to be excluded in the differential corrected by medial fixation of the kidney (to decrease
diagnosis of haematuria in pregnancy include: calculi; stretch on the renal vein) and excision of renal
tumours; renal parenchymal disease; trauma; bleeding varicosities (9).
and coagulation disorders; drugs; renal vein
thrombosis and emboli; endometriosis (4; 6). After In this particular case the patient did not want any
exclusion of organic causes of haematuria in further investigation in view of the fact that her
pregnancy, there would still be a number of cases for symptoms had settled and her investigations including:
which a definite cause of bleeding cannot be found by urine cytology; urine culture and urine flow cytometry;
routine clinical and urologic examination and these ultrasound scan of renal tract; full blood count; serum
cases would be classified as idiopathic. urea and electrolytes; liver function tests; and
coagulation screen were normal. It would be argued it
Brown and associates (7) reported that one thousand would be argued that flexible cystoscopy should have
pregnant women who attended for routine antenatal been done to complete her investigations to exclude
care in St George hospital and university of New any small bladder lesion but the patient did not want
South Wales in Australia were invited to have a routine any further investigation. It would also be counter
urinalysis and be referred to a nephrology clinic for argued that if the lady had any big any significant
further investigation if dipstick microscopic haematuria lesion in the urinary bladder the ultrasound scan would
was detected on more than one occasion before 32 have picked the lesion up therefore flexible cystoscopy
weeks gestation. In this study the main outcome was not absolutely necessary and that it would be
measures were the prevalence of dipstick haematuria sufficient to leave the lady alone to come back in the
confirmed by urine microscopy, and the development event of any further haematuria. The cause of
of preeclampsia or gestational hypertension or haematuria was not established in this case however,
delivery of a small-for-gestational–age baby. One it could be suggested that in the absence of any
hundred and seventy eight of 902 women (20%) who obvious pathology found during ultrasound scan of the
entered the study had dipstick haematuria on at least patient’s gross haematuria may be considered
2 occasions in pregnancy; 66 of 126 women (53%) provisionally to be related to the “Nutcracker
who had haematuria before 32 weeks attended the Phenomenon” but to be absolutely sure if her
nephrology clinic, where microscopic haematuria was haematuria subsequently recurs in the absence of
confirmed in 40 women (61%). Renal imaging results pregnancy or during any subsequent pregnancy she
were normal in all except 1 woman, and all women would need to have further investigations including:
had serum creatinine level of 0.90 mg/dl or less (< or = cystoscopy and bilateral ureteric urine sampling /
80 micromol/L). The development of preeclampsia or bilateral retrograde ureterogram / bilateral
gestational hypertension or the delivery of a ureteroscopies; renal angiography to exclude any rare
small-for-gestational-age baby, were similar in women cause of haematuria to complete her investigations at
with and without dipstick haematuria. Microscopic a time that she is not pregnant.
haematuria persisted in half (15 women) of those who
attended for follow-up after 3 months post partum. In a majority of cases of haematuria in pregnancy, no
Brown and associates concluded that: demonstrable cause can be found after investigations
and the bleeding spontaneously subsides in the
(a) Dipstick haematuria is very common during
pregnancy, but rarely signifies a disorder likely to
impact on the pregnancy outcome.

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postpartum. The haematuria events are explained by 6. Lindheimer M D, Davison J M. Hematuria in
rupture of small veins around the dilated renal pelvis in pregnancy. In: Principles and Practice of Medical
pregnancy. It is worthwhile realising that, Therapy in pregnancy. Ed-Gleicher N, 3rd edition,
investigations of gestational associated haematuria Appleton and Lange, Connecticut. 1998; 1074-1075.
almost invariably can be deferred until after delivery of 7. Brown M A, Holt J L, Mangos G J, Murray N, Curtis
the baby. Non–invasive investigative techniques like J, Homer C. Microscopic hematuria in pregnancy:
ultrasound scan and MRI are useful in arriving at such relevance to pregnancy outcome. Am J Kidney Dis.
decisions (9; 10). 2005; 45(4):667-673.
8. De Schepper A. Nutcracker phenomenon of the
If there is absence of a demonstrable cause of renal vein and venous pathology of the left kidney. J
haematuria in pregnancy, then the haematuria is Belge Radiol. 1972; 55: 507-511
classified as idiopathic and recurrence is said to be 9. Wendel R G, Crawford D E, Hehman K N. The
unlikely in the current or subsequent pregnancy (6). Nutcracker phenomenon: An unusual cause for renal
varicosities with hematuria. Journal of Urology. 1980;
Conclusions 123:761.
10. Lindheimer M D, Katz A I. The kidney and
q In a majority of cases of haematuria in pregnancy, no hypertension in pregnancy. In: The Kidney.
demonstrable cause can be found after Ed-Brenner B M, Rector F C. 4th edition. W B
investigations and the bleeding spontaneously Saunders Company, Jovanovich. 1991; 2: 1577.
subsides in the postpartum.
Author details
q The haematuria events are explained by rupture of
small veins around the dilated renal pelvis in Anthony Kodzo-Grey Delali Venyo
pregnancy. North Manchester General Hospital
Department of Urology
q Investigations of gestational associated haematuria Delaunays Road
almost invariably can be deferred until after delivery Crumpsall
of the baby. Manchester
M8 5RB
q Non–invasive investigative techniques like UNITED KINGDOM
ultrasound scan and MRI are useful in arriving at TEL: ++44 (0) 161 7202468
such decisions

q Midwives, General practitioners, obstetricians as well
as urologists need to be aware of the e approach to
gross haematuria in pregnancy in order to reassure
the patients and in order to guide these patients
through their pregnancies.

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in Pregnancy. Case Reports. can be found at: Crumpsall
http://bhj.org/journal/2001_4303_july01/case_432.htm Manchester
3. Harty J I. Neoplasms of urinary tract. In Principles M8 5RB
and Practice of Medical Therapy in pregnancy. United Kingdom
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